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Kultur Dokumente
Delivering Excellence in
Insurance Claims Handling
Contents
Page
1. Introduction
2. Executive Summary
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Figure:
Appendix:
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January 2009
6 Lloyds Avenue, London, EC3N 3AX, UK Telephone: 0207 480 7610 email:enquiries@airmic.co.uk
1. Introduction
AIRMIC wishes to thank its members and partners for their support and enthusiasm
displayed during workshops that supported the preparation of this best practice guide.
Claims handling service is the basis on which an insurance company is ultimately judged by
clients and the key issue affecting the reputation of the insurer. The payment of legitimate
claims represents the delivery of the promise at the heart of the insurance contract. Indeed,
for many insurance companies, excellent claims handling service is considered to be a
differentiator that distinguishes them from the competition.
Achieving excellence in claims handling should be a fundamental objective of any insurance
company. This AIRMIC guide considers the components that should be in place to comply
with best practice and the features of each component that need to be demonstrated.
There is a considerable amount of anecdotal and subjective evidence and opinion available
regarding the claims handling service provided by different insurance companies. This guide
provides the structure for an objective evaluation of claims handling capabilities.
The scope goes well beyond the KPIs that all claims handling operations have in place.
The guide also considers the attributes of the Culture, Resources, Operations and Procedures
(CROP) that need to be in place in order to deliver a best practice claims handling service.
Within the CROP, operations represent the processes by which claims are handled, whilst
culture, resources and procedures represent the framework that supports those processes.
Objective evaluation is necessary, so that the client can assess whether the claims handling
capabilities of the insurer are aligned with the requirements of the insured. Insurance
companies need to evaluate their claims handling function in an objective and structured
way, so that the capabilities can be presented to clients in a manner that enables the
insurance buyer to make comparisons.
Evaluation against the structure set out in this guide will also enable the insurance company
to identify the necessary improvements to claims handling capabilities, so that excellence
may be achieved and demonstrated.
This guide is substantially directed at the claims handling requirements of larger clients,
although the principles also apply to more routine, higher volume claims handling operations.
Likewise, these principles apply to the handling of disease claims, although this is a specialist
area. In general, however, it is the larger, more complex organisations that require greater
sophistication from claims handling departments.
Large, complex claims do not arise very often. Therefore, large corporate clients require
objective and detailed reassurance in advance that they will be handled in an efficient,
effective and appropriate manner.
The ultimate test or objective is that claims are handled in a consistent, yet flexible and
fair manner that is transparent, accurate and timely, as well as secure and compliant.
This outcome will deliver the necessary features of partnership with clients and (as
appropriate) insurance brokers.
This guide was developed during a series of workshops attended by AIRMIC members,
together with insurance company, insurance broker and loss adjuster partners. AIRMIC is
grateful for their continuing enthusiasm and support, which has made possible the production
of this comprehensive guide to best practice in insurance claims handling.
2. Executive Summary
The objective is to achieve a claims handling culture and service that ensures
claims are managed in a consistent, yet flexible and fair manner that is transparent,
accurate and timely, as well as secure and compliant
Excellence in claims handling is a competitive edge for an insurance company and it is a
service that clients greatly value. Payment of legitimate insurance claims for losses that have
been suffered by the insured is the primary reason for buying insurance. The purpose of this
guide is to enable claims handlers to undertake a detailed evaluation and then report to
clients and client prospects on their claims handling capabilities.
The guide is structured to provide information on the key components that must be in place in
order to deliver excellence in insurance claims handling. It describes eight components
as follows:
1. Culture and Philosophy
2. Communications
3. People
4. Infrastructure
5. Claims Procedures
6. Data Management
7. Operations
8. Monitoring and Review
Each of these components must be present for the organisation to demonstrate that it has
the required Culture, Resources, Operations and Procedures in place. The relationship between
these eight components is described and illustrated by the figure at the end of the guide.
Several features are identified in respect of each individual component and these are
summarised in the Appendix to provide a Checklist of Best Practice.
As well as evaluating current performance so that clients can be provided with an overview of
the claims handling capability of the organisation, the best practice guide can also be used as
a means of identifying components and / or features of the claims handling capability that
require improvement.
Component 2: Communications
Arrangements for effective, efficient and transparent communication with the insured and all
other relevant stakeholders
Component 3: People
Suitable and sufficient number and range of skilled, qualified and experienced personnel, with
emphasis on development, training and supervision
Component 4: Infrastructure
IT and other non-people resources sufficient to handle the number, value, nature and
complexity of claims and communications with all stakeholders
Component 5: Claims Procedures
Client-focused procedures designed and implemented to support and enhance the claims
handling processes and activities
Component 6: Data Management
Structured protocols for the secure management and analysis of all relevant data in
compliance with legal and regulatory requirements
Component 7: Operations
Handling of claims in a consistent, yet flexible and fair manner that is transparent, accurate
and timely, as well as secure and compliant
Component 8: Monitoring and Review
Arrangements for routine review of claims performance, capabilities and procedures, including
evaluation of client satisfaction
2. Communications
I Documented and shared claims service structure specific to the client with arrangements
for review of the structure on a periodic basis
I Established roles and responsibilities for the client service team with appropriate level of
seniority of the team for the size, nature and complexity of the client
I Communications structure established specific to client with arrangements for escalation
of communications and access to decision makers
I Arrangements for claims staff to meet client pre-placement and regularly thereafter, so
that claims staff gain knowledge of client operations and activities
I Documented procedures for supply of appropriate claims data on a confidential basis,
especially in relation to reserves and movements in reserves
I Client complaint and other feedback processes established and shared with the client with
promises on timescales and remedies available
I Communication protocols established with relevant co-insurance and excess markets to
ensure coordinated and consistent handling of large claims
3. People
I Case load / skills model used to determine necessary staffing skill, qualification and
experience levels with appropriate staffing numbers identified
I Sufficient staff available for the size, nature and complexity of the sector, risks and claims,
including large and / or complex claims
I Succession planning arrangements established and linked to career path planning to
ensure continuous staff skills development and improvement
I Specific assignment of senior staff to large accounts with necessary levels of authority to
make decisions and ensure appropriate level of client service
I Staff retention levels established and achieved to ensure continuity and availability of
sufficient skilled and experienced staff for client profile
I Clearly established job descriptions for all staff that specify level of authority and required
level of supervision when undertaking specific tasks
I Personal development plans for staff with CPD and training records and evaluation of skills
by way of a skills profile analysis and annual appraisals
4. Infrastructure
I Appropriate IT systems specifically designed for handling claims and capable of handling
data in an efficient manner and producing appropriate reports
I Planned investment in claims handling IT infrastructure to eliminate any legacy systems
and ensure adequate future investment to maintain excellent service
I Business plans in place to develop and continuously enhance the IT infrastructure and
ensure high degree of compatibility with market and client systems
I Suitable communication networks with clients and insurance markets that are kept up to
date with technology and data interface protocols
I Premises that are appropriate in number, location and facilities to provide efficient and
effective client support at all times and in specified territories
5. Claims Procedures
I Written and agreed procedures that are flexible and bespoke to the client and reflect the
number, value, nature and complexity of anticipated claims
I Procedures for the involvement and control of specialist advisers, including loss adjusters,
forensic accountants and other specialists
I Commitment to adhere to the AIRMIC protocol on Reservation of Rights with
enhancements for specific clients, as appropriate
I Established timescales for claims processing that provide transparency and access to
decision makers at all stages in the claims handling process
I Subrogation procedures established that describe the protocols and clearly state
client requirements and responsibilities
I Rehearsal exercises to stress-test client claims scenarios, involving all interested parties,
with procedures for implementing the lessons learnt
I Management of run-off claims described in the procedures to ensure satisfactory handling
of legacy claims should the client change insurers
6. Data Management
I Access controls and other procedures in place to ensure data protection, integrity and
compliance with data protection obligations
I Mechanisms and controls to ensure that data is reliable and accurate, including data input
records to validate data entry details and staff identity
I Systems in place to identify suspicious claims and invalid data and detect and investigate
claims that appear to be fraudulent or inaccurate
I Data retention, analysis and sharing protocols established defining data management
standards that provide support for claims handling activities
I Robust business continuity and disaster recovery plans to ensure that there is no
unplanned disruption to data management activities
7. Operations
I Documented flowcharts to record processes and levels of authority that include flowcharts
and are shared with the client and other interested parties
I Involvement and management of third party service providers controlled by written
agreements and deadlines established for third party reports
I Adequately experienced and qualified senior staff always available to supervise operations,
ensure regulatory compliance and adherence to established procedures
I Consistent interpretation of policy terms and conditions by validated routine operational
review and by auditing of open and closed files as necessary
I Procedures, including payment authorisation procedures, in place to ensure minimum time
between claim settlement and payment
I Minutes of meetings and other records of client discussions produced after all claims
review meetings to confirm agreed actions
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Claims Procedures
Data Management
Operations
Communications
Infrastructure
People
Support
Influence
Evaluate
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2. Communications
I Communications structure established specific to client
I Established roles and responsibilities for client service team
I Documented claims structure and escalation arrangements
I Claims staff meet client pre-placement and at regular reviews
I Documented procedures for supply of claims data
I Client feedback processes established
I Communication protocols with following / excess markets
3. People
I Case load / skills model used to determine required staffing levels
I Sufficient staff for the size, nature and complexity of the claims
I Succession planning arrangements formally established
I Personal development plans for staff with annual appraisals
I Staff retention levels established and achieved
I Specific assignment of senior staff to large accounts
I Clearly established job descriptions for all staff
4. Infrastructure
I Appropriate IT systems specifically designed for handling claims
I Planned investment in IT to eliminate any legacy systems
I Business plans to develop and enhance infrastructure
I Suitable communication networks with clients and markets
I Premises that are appropriate in number, location and facilities
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5. Claims Procedures
I Agreed claims procedures that are flexible and bespoke to the client
I Procedures for the involvement of specialist advisers
I Adoption of the AIRMIC Reservation of Rights protocol
I Established timescales for claims processing
I Subrogation procedures, including client responsibilities
I Stress-testing of client claims scenarios involving claims staff
I Management of run-off claims described in the procedures
6. Data Management
I Access controls in place to ensure data protection and integrity
I Data input records to validate data entry mechanisms and controls
I Systems in place to detect fraudulent claims / inaccurate data
I Data retention, analysis and sharing protocols established
I Robust business continuity and disaster recovery plans in place
7. Operations
I Flow charts to record processes and levels of authority
I Workload analysis and management of third party service providers
I Adequately experienced and qualified senior staff to supervise operations
I Consistent interpretation of policy terms and conditions
I Minimum time between claim settlement and payment
I Minutes of meetings and other records of client discussions
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